Beyond Autism — A Collaborative Approach
LAUNCH — School readiness for young learners. A program by Beyond Autism

Intake Questionnaire

To better acquaint us with your child, please complete this form. Only the fields marked * are required; share as much as you can.

About your child

Medical / health

History of seizures

Educational

What services is your child receiving? (select all that apply)
Is your child able to sit at a desk and complete a task?
Is your child able to work independently?
Does your child participate in (select all that apply)
Does your child require 1:1 support to be successful?
Is your child receiving or has your child previously received ABA therapy?
Permission to contact this agency?

Communication

What form(s) of communication does your child use? (select all that apply)
Does your child use a different communication system at home than at school?
Does your child request desired items or activities spontaneously?
Is your child able to follow directions when asked to complete small tasks around the house (i.e. shut the door, come here, wash your hands)?

Safety

Does your child exhibit safety awareness in parking lots, near water, in the community?
Does your child exhibit safety while riding in vehicles?
Does your child have a history of elopement?
Does your child react appropriately when asked to hold their hand/arm for safety purposes?
Does your child place inedible objects in their mouth?
Choking hazard?

Behavioral

Does your child have a current Behavior Intervention Plan?
Does your child require a 1:1 aide to manage their behavioral needs?
Does your child exhibit any self-injurious (towards self) or aggressive (towards others) behaviors?
Does your child exhibit disruptive/challenging behaviors with any of the following?
Noisy environments
Changes to schedule
Waiting
Taking turns
During non-preferred tasks
Being told “no,” “not now” or “later”
Limited access to preferred item(s)
Transitions
Trips to stores, barber, dentist, etc.
During mealtime
Completing the bathroom routine

Sensory

Does your child seek out (select all that apply)
Does your child have any aversions to odors, textures, sounds, eye contact, taste?

Life / functional skills

How would you describe your child’s level of independence in the following areas?
Eating / drinking
Toileting
Brushing teeth, hair
Dressing, undressing
Handwashing

Play / leisure

Goals

In order of priority, please rate your goals for your child (1 = greatest, through 5 = least)

Commitment

Are you, the family, willing to work collaboratively with our team and actively participate in your child’s education?

Documents

Please attach your child’s current IEP, MET, BIP and the most recent diagnostic evaluation(s) that will assist our team in determining if placement is appropriate for your child.

    Signature

    Submitting this intake form begins an exploratory review and does not guarantee enrollment. Our team may request additional information, documentation, and/or an observation to determine whether LAUNCH is an appropriate fit for your child. We are committed to open, honest communication throughout this process, with the goal of establishing a collaborative relationship built on mutual trust and a shared commitment to your child’s success.